U01.07.052 Syphilitic heart disease

Syphilitic heart disease is a late-stage cardiovascular complication of tertiary syphilis. It primarily affects the aorta, leading to significant structural damage due to inflammation of the vasa vasorum, the small vessels that supply the aortic wall.

Pathophysiology

Cause: Chronic infection with Treponema pallidum (tertiary stage).
Mechanism:
- Inflammation and obliteration of the vasa vasorum → ischemic damage to the aortic wall.
- Atrophy and dilation of the vessel wall and valve ring.
- Disruption of connective tissue leads to aneurysm formation.

Key Features

Feature	Description
Aortic involvement	Dilation of the aortic root, ascending aorta, and aortic arch.
Calcification	May affect the aortic root, ascending aorta, and thoracic aorta.
“Tree Bark” Appearance	Caused by scarring and fibrosis of the aortic wall.
Complications	Aneurysm of the ascending aorta or aortic arch, leading to aortic insufficiency.

Clinical Consequences

Aortic aneurysm: Risk of rupture and dissection.
Aortic regurgitation: Due to dilation of the aortic valve ring.
Heart failure: Resulting from chronic volume overload.

USMLE Step 1 Pearls

Vasa vasorum obliteration is a hallmark feature of tertiary syphilis.
Aneurysm + aortic regurgitation in a patient with a history of syphilis → Consider syphilitic heart disease.
Histology: Disruption of elastic fibers with plasma cell infiltration.

Points to Remember

Tertiary syphilis damages the aorta, leading to aneurysms and aortic valve incompetence.
Look for calcifications and the “tree bark” appearance on imaging.
Serologic testing (FTA-ABS, RPR) confirms syphilis diagnosis.
Treatment: Penicillin G can halt disease progression but does not reverse damage.

Bibliography & References

Fauci AS, Kasper DL, Hauser SL, et al. Harrison’s Principles of Internal Medicine. 21st ed.
Kumar V, Abbas AK, Aster JC. Robbins and Cotran Pathologic Basis of Disease. 10th ed.
CDC Guidelines for Syphilis Management – CDC.gov

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